Measure Abbreviation
PONV-02
Data Collection Method

This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data. This measure is explicitly not based on provider self-attestation.

Measure Type
Process
Description

Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.

The purpose of this process of care measure is to reduce the incidence of postoperative nausea and vomiting in pediatric patients.

Measure Time Period

Preop through Recovery Room In

Inclusions

All patients, age 3 through 17 years of age, who undergo any procedure under general anesthesia in which an inhalational general anesthetic between Anesthesia Start and Anesthesia End is used for maintenance AND who have two or more risk factors for POV.

POV Risk Factors:

  • Age ≥ 3 years
  • History of POV or Post-Operative Nausea and Vomiting (PONV) in patient, parent or sibling
  • Strabismus surgery (Indicated by CPT: 00140 or procedure text listed as ‘strab’ ‘eye’ ‘ocular’ or ‘lacrimal’)
  • Surgery ≥ 30 minutes
Exclusions
  • Patients < 3 or > 17 years old.
  • Patients transferred directly to the ICU
  • Procedures on the Neck (CPT 00326)
  • Intrathoracic Procedures (CPT 00561)
  • Procedures on the Lower Abdomen (CPT 00834)
  • Labor Epidurals (CPT 01967, 01968, 01969)
  • Endoscopy (CPT 00740, 00810)
  • Obturator neurectomy (CPT 01180, 01190)
  • Shoulder cast application (CPT 01682)
  • Obstetric Non-Operative Procedures with procedure text: “Labor Epidural”
  • Cases in which an inhalation anesthetic is used only for induction
Success

Patient receives combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively

Anti-emetic therapy:  The recommended pharmacologic anti-emetics for PONV prophylaxis in pediatric patients at risk for moderate to severe PONV include (but may not limited to):

  • 5-Hydroxytryptamine (5-HT3) Receptor Antagonists (Recommended as the first choice for prophylaxis for POV in children)
  • Glucocorticoids
  • Anticholinergics
  • Antihistamines
  • Butyrophenones
  • Phenothiazines
  • Phenylethylamines
  • NK-1 Receptor Antagonists

Note: In addition, propofol infusion is accepted as one of the antiemetic options for this measure. The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA’s web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications.

Other Measure Build Details
  • For a case to be included for the PONV 02 measure, the patient must have received inhalational general anesthetic for maintenance purposes AND have two or more risk factors for POV. This measure determines maintenance as any inhalational general anesthetic administered after procedure start (MPOG Concept 50006).

  • Values for flows and gases will be assessed and considered artifact if less than the following ranges and the patient did not receive any other inhalational general anesthetics greater than these ranges:

    • Nitrous Oxide Flows: <0.2 L/min
    • Isoflurane Insp %: <0.2%
    • Sevoflurane Insp %: <0.5%
    • Desflurane Insp %: <0.5%
    • Nitrous Oxide Insp % <15%
  • All anesthetic gas values prior to Procedure Start are excluded. If no Procedure start, Induction End is used.
  • This measure requires CPT codes to be transferred to the MPOG database for cases to be included. Those sites participating with this measure must have current pro fee procedure data in the MPOG Central database- refer to the flow diagram on page 7 of this specification for more details.

Algorithm for determining Measure End Time:

  1. Recovery Room In Date/Time. If not available then,
  2. Phase I Recovery Room In Date/Time. If not available then,
  3. Phase II Recovery Room In Date/Time. If not available then,
  4. Patient out of Room. If not available then,
  5. Data Capture End. If not available then,
  6. Anesthesia End.

Algorithm for determining Case Length:

Case Start:

  1. Anesthesia Induction End. If not available, then
  2. Anesthesia Induction Start. If not available, then
  3. Procedure Start. If not available, then
  4. Patient in Room. If not available, then
  5. Anesthesia Start

Case End:

  1. Patient Extubated. If not available, then
  2. LMA Removal Time. If not available, then
  3. Procedure End. If not available, then
  4. Patient Out of Room. If not available, then
  5. Anesthesia End
Responsible Provider

Provider(s) signed in at Induction End.

Method for determining Responsible Provider:

  1. Provider signed in at Anesthesia Induction End. If not available then,
  2. Provider signed in at Anesthesia Induction Begin. If not available then,
  3. Provider signed in at Procedure Start. If not available then,
  4. Provider signed in at Patient in Room. If not available then,
  5. Provider signed in Anesthesia Start.
Threshold
90%
MPOG Concept IDs Required

General Inhalational Anesthetic MPOG Concept IDs

3297

Enflurane Exp %

3298

Enflurane Insp %

3006

Isoflurane actual consumption (ml)

3007

Desflurane actual consumption (ml)

3260

Isoflurane Exp %

3265

Isoflurane Insp%

3280

Desflurane Exp %

3285

Desflurane Insp %

50420

Cardiopulmonary bypass – Isoflurane vaporizer turned on

3008

Sevoflurane actual consumption (ml)

3270

Sevoflurane Exp %

3275

Sevoflurane Insp %

3503

Sevoflurane (mmHg)

3250

Nitrous Insp %

3255

Nitrous Exp %

Antiemetic MPOG Concept IDs (by class)

Class: 5-Hydroxytryptamine (5-HT3) Receptor Antagonists

10335

Ondansetron

10164

Dolasetron

10208

Granisetron

10711

Palonosetron

Anticholinergics

10400

Scopolamine Patch

10399

Scopoloamine

11040

Butylscopolamine

Antihistamines

10257

Dimenhydrinate

10160

Diphenhydramine

Butyrophenones

10169

Droperidol

10210

Haloperidol

Neurokinin-1 Receptor Agonists

10035

Aprepitant

10719

Fosaprepitant

Phenothiazines

10374

Promethazine

10373

Prochlorperazine

Steroids

10147

Dexamethasone

10296

Methylprednisolone

Prokinetic

10297

Metoclopramide

 

 

10377

Propofol (Infusion only)

 

 

PONV Medical Reason Exclusion MPOG Concept ID

50046

Medical Performance Exclusion - PONV

PONV Risk Factor- History of PONV/Motion Sickness MPOG Concept IDs:

70225

Assessment and Plan - Comments

70302

Assessment and Plan - Anesthetic Consideration

70338

General - PONV Risk Factors

70339

General - PONV Risk Total Score

70080

General - Previous Anesthetic Problem

Data Diagnostics Affected
  • Percentage of Cases with Professional Fee Procedure Codes
  • Percentage of Cases with Antiemetic Medications
  • Percentage of Intraoperative Notes with a Meaningful Note Mapping
  • Percentage of Preoperative Notes with a Meaningful Type Mapping
Rationale

Postoperative nausea and vomiting (PONV) is a common and unpleasant outcome of anesthesia care that can lead to other complications, lengthening the patient’s recovery period after surgery2. Effective management of PONV leads to optimal patient outcomes and comfort during the postoperative period.3 Combination therapy that includes two prophylactic pharmacologic anti-emetic agents of different classes is most effective when managing PONV in children.4,5

A separate PONV risk model should be considered for pediatric patients as many proven risk factors for adults are difficult to assess or do not apply to children.6 The independent PONV risk factors identified for pediatrics include duration of surgery greater than 30 minutes, age greater than 3 years old, positive history of PONV (individual and/or immediate family) and strabismus surgery.6 Although including a prophylactic anti-emetic administration protocol that considers such risk factors has shown to reduce the incidence of PONV, there is high variability in this outcome.7,8

References
  1. Gan TJ, Meyer TA, Apfel CC, et al. Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2007;105(6):1615-1628, table of contents.
  2. Gillmann HJ, Wasilenko S, Zuger J, et al. Standardised electronic algorithms for monitoring prophylaxis of postoperative nausea and vomiting. Archives of medical science : AMS. 2019;15(2):408-415.
  3. Collins AS. Postoperative nausea and vomiting in adults: implications for critical care. Critical care nurse. 2011;31(6):36-45.
  4. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesthesia and analgesia. 2014;118(1):85-113.
  5. Shen YD, Chen CY, Wu CH, Cherng YG, Tam KW. Dexamethasone, ondansetron, and their combination and postoperative nausea and vomiting in children undergoing strabismus surgery: a meta-analysis of randomized controlled trials. Paediatric anaesthesia. 2014;24(5):490-498.
  6. Eberhart LH, Geldner G, Kranke P, et al. The development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients. Anesthesia and analgesia. 2004;99(6):1630-1637, table of contents.
  7. De Oliveira GS, Jr., Castro-Alves LJ, Chang R, Yaghmour E, McCarthy RJ. Systemic metoclopramide to prevent postoperative nausea and vomiting: a meta-analysis without Fujii's studies. British journal of anaesthesia. 2012;109(5):688-697.
  8. Schraag S, Pradelli L, Alsaleh AJO, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC anesthesiology. 2018;18(1):162.